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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
Left Hemicolectomy andTotal Colectomy
27
KamilErozkan andEmreGorgun
Background
With the advent of minimally invasive surgical strategies, the landscape of surgical
practice has undergone a paradigm shift. Laparoscopic colectomy, which is now
widely performed for benign and malignant conditions, has demonstrated advantages, such as reduced pain, lower incidence of ileus, and shorter hospital stays.
These outcomes have propelled surgeons to explore newer, minimally invasive
approaches to diminish the operative trauma, shorten hospital stays, and enhance
operative visualization and dexterity. Surgeons, drawn to less-invasive techniques
with comparable efcacy, are now immersed in the discourse surrounding robotic
surgery [1, 2].
The inherent technical challenges of laparoscopic colon surgery, characterized
by anatomical complexities and a demanding learning curve, have led to increased
adoption of robotic systems. Particularly advantageous in challenging anatomical
regions such as the pelvis, these systems provide high-denition three-dimensional
vision, surgeon motion ltration, articulating instrument movements, stable camera
control, retraction, and improved ergonomics [3]. The fatigue associated with
unnatural positions during laparoscopy can be mitigated using robotic technology
[4]. These advantages address the limitations of laparoscopic surgery and potentially reduce the learning curve of minimally invasive colorectal surgery [5].
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 86927- 3_27.
K. Erozkan · E. Gorgun (*)
Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic,
Cleveland, OH, USA
e-mail: erozkak@ccf.org; gorgune@ccf.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_27
365
366
K. Erozkan and E. Gorgun
The da Vinci® robotic surgical system (Intuitive Surgical, Inc., Sunnyvale, CA,
USA) has further catalyzed this evolution, particularly in colon and rectal surgeries.
Since its rst reported application in 2002, robotic colorectal surgery has gained
momentum for both benign and malignant resections. Insights from a populationbased study involving patients undergoing colectomy have revealed a noteworthy
surge in the use of robotic colectomy. Robotic colorectal surgery increased from
0.7% in 2006 to 10.9% in 2010 within all colorectal procedures across all hospitals.
Furthermore, in hospitals with the highest adoption rate of robotic colectomy, the
utilization of robotic colectomy escalated even more signicantly, moving from 0.8
to an impressive 32.8% among all colectomies [6]. Another study from 2012 to
2018 echoed this trend, reporting a substantial rise in the prevalence of robotic colectomy from 2.5% to 16.3% [1].
Despite its advantages, robotic surgery has several limitations. A notable data
gap exists concerning the long-term oncological outcomes of robotic colon cancer
surgery, and the escalated cost associated with robotic techniques is a considerable
hurdle to its widespread adoption. In addition, maintenance requirements and extra
training are additional limitations. While the predominant focus on the application
of robotics in colorectal surgery has been directed toward rectal cancer and dissection within the narrow pelvis, it is imperative to underscore its pivotal role in other
procedures, particularly left hemicolectomy and total colectomy. This chapter
delves into the evolving landscape of robotic left hemicolectomy and total colectomy, emphasizing the indications, operative steps, and future directions. By meticulously exploring these procedures, we aimed to contribute to a broader
understanding of robotic colectomies, their challenges, and potential avenues for
improvement, thereby facilitating the continued evolution of minimally invasive
colorectal surgery.
Indications
Left hemicolectomy and total colectomy represent crucial surgical interventions
employed for various indications, and the decision to perform robotic colectomy is
typically based on the patients’ specic condition and surgeons’ prociency. The
indications for robotic surgery are similar to those for laparoscopic surgery.
Precancerous polyps, endometriosis involving the colon, diverticular disease, left
hemicolectomy, or sigmoid resection are the preferred surgical interventions for
left-sided colon cancer. The preferred surgical intervention for tumors situated in
the segment of the colon between the left colic vessels and the initial sigmoidal
branches is a “true” left hemicolectomy [7]. This procedure entails complete
removal of the left colon, including the origin of the inferior mesenteric artery
(IMA) and its associated lymphatic territory. Alternatively, tumors in this location
may undergo segmental resection. This less invasive approach involves only the
division of the left branch of the middle colic and left colic vessels while preserving
the root of the IMA and main sigmoidal vessels. Importantly, this method does not
compromise oncological outcomes [8].
27 Left Hemicolectomy andTotal Colectomy
367
However, it is crucial to note that indications for total colectomy are limited.
Despite the restricted scope, we believe that a comprehensive discussion on these
indications is valuable. Depending on the tumor location, synchronous cancer may
require total colectomy [9, 10]. Conditions such as familial adenomatous polyposis,
juvenile polyposis, MUTYH-associated polyposis, and Peutz-Jeghers syndrome,
characterized by diffuse adenomatosis of the colon, are additional indications for
total colectomy to reduce the risk of colorectal cancer development [10, 11]. Total
colectomy is recommended for patients with hereditary nonpolyposis colorectal
cancer (HNPCC) syndrome because of the elevated risk of synchronous or metachronous colorectal cancers [12]. Inammatory bowel diseases, including ulcerative colitis and Crohn’s disease, may prompt total colectomy when medical
management fails or in the presence of complications such as refractory disease,
dysplasia, or severe inammation [13–15]. Surgical management is indicated for
patients with Clostridium difcile infections who do not respond to medical treatment [16]. When conservative measures are ineffective, conditions marked by
impaired colonic motility, such as slow-transit constipation or colonic inertia, can
be addressed with total robotic colectomy [17, 18]. Total robotic colectomy may be
considered in cases of endometriosis or diverticular disease involving the different
sides of the colon.
However, surgical emergencies, previous abdominal surgery with extensive
adhesions, cardiovascular or respiratory disease preventing safe pneumoperitoneum, or highly complex diseases may pose contraindications to most minimally
invasive approaches including robotics. Notably, obesity does not serve as a contraindication to robotic surgery, as evidenced by the comparable short-term outcomes
between the robotic and laparoscopic approaches in obese patients. Moreover, the
robotic approach has shown accelerated postoperative recovery compared with its
laparoscopic counterpart [19]. It is paramount to emphasize that the decision to
perform robotic left hemicolectomy and total colectomy is personalized, considering many factors encompassing the patients’ overall health and surgeons’ expertise.
This individualized approach ensures optimal patient outcomes and aligns with the
evolving landscape of colorectal surgery.
Preoperative Planning andRoom Setup
Proper patient selection is paramount in preoperative planning and candidates
should be medically t and capable of tolerating laparoscopy. A comprehensive
evaluation, including a detailed history and physical examination, is essential for all
patients undergoing colon surgery.
Preoperative colonoscopy and exible sigmoidoscopy are recommended in
patients with left-sided colonic or rectal lesions. Flexible sigmoidoscopy provides
valuable information regarding the distance from the anal verge to the lower edge of
the tumor, aiding operative planning. It is imperative to underscore the role of total
colonoscopy in eligible patients to rule out the potential presence of synchronous
tumors effectively. Patients are given mechanical bowel preparation with oral
368
Fig. 27.1 Modied
lithotomy position in
robotic surgery
K. Erozkan and E. Gorgun
antibiotics as part of the preoperative preparation. This protocol is rigorously
enforced in our practice to maintain a low incidence of postoperative site infections.
Preoperative intravenous antibiotics are administered within 30–60min of incision,
ensuring adequate concentration at the outset [20]. Deep venous prophylaxis
includes the use of sequential compression devices coupled with chemical prophylaxis, in the form of preoperative heparin.
After informed consent is obtained, intravenous induction is performed, followed by endotracheal intubation. A urinary catheter and orogastric tube are placed
in all cases. During the surgical procedure, patients are positioned in a modied
lithotomy position, with Allen® Yellon® or Yellon Elite™ Stirrups (Allen Medical,
Acton, MA, USA) utilized to prevent peroneal nerve injury (Fig.27.1). This positioning offers the advantage of creating additional space for an assistant, easy access
to the anus for intraoperative colonoscopy if needed, and transanal stapler use and
facilitates anastomosis formation. Both arms are tucked at the sides. Gel pads are
used for decubitus support and additional stability. The operating table is adjusted
in slightly Trendelenburg position during the procedure. To prevent injuries and
ensure patient safety, we prefer to secure the patient further with a strong tape
around the chest area, mitigating the potential risk for patient sliding. The entire
abdomen is prepared using standard sterile surgical draping. Two monitors on both
sides of the table should be routine in laparoscopic surgery, and a robotic view
should be added to these monitors via a wire connection for the bedside assistant.
This setup is also helpful in hybrid procedures in which part of the operation is
performed using a laparoscopic approach.
This meticulous approach to patient selection and preoperative planning aims to
optimize outcomes, minimize complications, and create a conducive environment
for successful execution of colon and rectal surgical procedures.
27 Left Hemicolectomy andTotal Colectomy
369
Operation Steps
Left Hemicolectomy
The patient’s cart is positioned to the left of the patient (Fig.27.2), legs kept slightly
separated, and positioned in Trendelenburg position, typically angled at 10–15°,
with a lateral tilt to the right, also approximately 10–15° head down. This specic
positioning aids in moving the omentum and intestines cephalad, thereby facilitating a clear view of the sigmoid/left colon during the procedure. In cases where the
small intestine obstructs the view and dissection planes, RAY-TEC X-Rayable
Sponge (Johnson & Johnson Medical, Inc., Arlington, TX, USA) can be introduced
through the 8mm assistant trocar, allowing the assistant to gently push it on, moving the small bowel as a single unit out of the surgical eld. Alternatively, enveloping the small intestine like a cocoon using a RAY-TEC X-Rayable Sponge inserted
through the Pfannenstiel incision can be another solution after the Pfannenstiel incision. However, this is not our choice of approach as it requires an additional incision
side. Before docking the robotic system, adjustments to the patient’s position are
crucial to ensure optimal exposure of the surgical eld. It is important to note that
the robotic system is docked and the operating table cannot be moved unless it is
equipped with a motion-activating table such as TruSystem® 7000dV (Trumpf
Medizin Systeme GmbH & Co. KG software, Saalfeld, Germany). TruSystem®
7000dV is an advanced motion-activating table that enables precise surgical table
movement across multiple quadrants [21].
To perform robotic left colectomy or sigmoid resection, ve ports, including the
camera and assistant ports, are required [22]. The choice of port placement technique depends on the location of the pathology and surgeon’s preference. For sigmoid and distal descending colon resections, a line is drawn from the right lower
quadrant to the left midclavicular line intersecting the left subcostal border. Port 2
is initially placed at the junction of this line with the midline. After camera insertion, the procedure begins with an examination of the abdominal cavity to rule out
metastatic disease. Subsequent trocars are positioned at least 8cm apart following
the pneumoperitoneum under direct visualization (Fig.27.3). Different port placement techniques can be used in some centers (Fig.27.4). In cases involving the
proximal descending colon and splenic exure lesions, ports are inserted, as shown
in Fig.27.5. This alternative port placement technique facilitates a single-docking
surgical procedure during splenic exure mobilization. As in the authors of this
chapter, we generally use the alternative port placement technique in all left-sided
colectomies. The assistant port is strategically placed as far as possible from the da
Vinci® ports and lateral to the right of the midclavicular line. These assistant ports
play a crucial role in small bowel and colon retraction, and suction irrigation.
Subsequently, the greater omentum is retracted cephalad and extended over the
370
K. Erozkan and E. Gorgun
a
b
Fig. 27.2 (a) Room setup during left hemicolectomy. (b) Trendelenburg position and position of
the patient cart
27 Left Hemicolectomy andTotal Colectomy
Fig. 27.3 Port placement
during left hemicolectomy
(double docking)
Fig. 27.4 Alternative port
placement for proximal
descending colon and
splenic exure lesions
371
372
K. Erozkan and E. Gorgun
transverse colon. Simultaneously, the small bowel is retracted medially and positioned on the right side of the abdominal cavity, which revealed the mesentery of the
left colon.
The preferred approach for dissection during robotic left colectomy or sigmoid
resection generally involves a medial-to-lateral orientation, although the lateral
approach can be considered based on the surgeon’s comfort level. Comparable outcomes were identied in the type of approach employed in colorectal cancer operations [23, 24]. The dissection begins by incising the right lateral superior pelvic
peritoneal reection using monopolar electrocautery. This incision starts inferiorly to
the sacral promontory and progresses superiorly to the inferior mesenteric artery
(IMA). The dissection is continued in a medial-to-lateral direction, reaching the left
lateral peritoneal reection. Simultaneously, the superior rectal artery is swept anteriorly, and the superior hypogastric nerves moved posteriorly. Identication and ligation of the superior rectal/inferior mesenteric vessels occur after the visualization and
preservation of the left ureter. Intraureteral indocyanine green (ICG) can be used as
an adjunct for ureteral identication during robot-assisted surgeries. This can be performed using a rigid cystoscope by inserting a 5 Fr open-ended ureteral catheter up
to 20cm. A gentle injection of 5mL of 2.5mg/mL ICG is performed as the ureteral
catheter is withdrawn from the ureteral orice. No stent is left in place, and the intraureteral ICG is detected using robotic near-infrared laser uorescence technology.
Depending on the surgical indication, high ligation of the IMA or its branches may
or may not be required. In robotic left colectomy for cancer, it is preferable to ligate
the left branch of the middle colic vessels, identied at the root of the small bowel
mesentery, and divided at the base of the transverse mesocolon. If high ligation is
deemed necessary, the takeoff of the IMA from the aorta is meticulously dissected to
avoid injury to the lumbar sympathetic (L1–L3) and superior hypogastric nerves.
Various modalities, such as staplers, Hem-o-lok clips, sutures, and robotic vesselsealing energy devices, can be employed for vessel ligation. Additionally, ligation of
the inferior mesenteric vein immediately below the level of the pancreatic body provides increased mobility to the proximal colon segment and entering to the lesser sac.
Although splenic exure mobilization is somewhat easier with the da Vinci Xi®
system [25, 26], it remains a complex and challenging step. Some centers opt for
double docking, but this approach is time-consuming. After working on the rst
target anatomy, the da Vinci Xi® is undocked, its boom is rotated 180°, and it docks
again to the same ports, enabling it to reach the second target anatomy. The robotic
arms are oriented toward the upper left quadrant of the patient to mobilize the
splenic exure during robotic left colectomy or sigmoid resection. This process
begins by adjusting arm 1 to the maximum exion, aiming to create space between
the arms, enhance reach, and prevent interference. In our practice, we deviate the
standard port placement line 15–20° counterclockwise and favor a single-docking
cross-armed approach (Fig.27.5).
In our practice, we prefer single-docking crossed-arm technique. Using a tip-up
fenestrated grasper through port number one, we retract the descending colon medially and inferiorly toward the cecum (Fig.27.6a). Subsequently, we cross the arms
27 Left Hemicolectomy andTotal Colectomy
Fig. 27.5 Alternative port
placement for singledocking cross-armed
technique
373
a
b
c
Fig. 27.6 (a) Traction of descending colon. (b) Lateral aspect of arm one. (c) Medial aspect
of arm one
374
K. Erozkan and E. Gorgun
without robotic arm collision from the lateral aspect of arm one, facilitating splenic
exure takedown (Fig.27.6b). Once lateral side dissection is completed, we adjust
the instrument positions to mobilize the transverse colon. The tip-up grasping
instrument retracts the colon toward the left lower quadrant, allowing us to work in
the medial aspect of port number one without restriction (Fig.27.6c). This “singledocking crossed-arm technique” offers freedom of movement and efciency and
saves time compared to double docking (Video 27.1) [27].
The mesentery of the colon to be resected is fully divided intracorporeally using
a vessel sealer. We highly encourage ICG utilization to assess perfusion in the
remaining colon segments. Finally, the bowel wall is transected proximally and distally using a robotic stapler, typically requiring a single ring depending on the level
of transection. After insertion of the wound protector, the specimen is extracted
through the 12mm robotic port#4. Proximal transection can be performed extracorporeally using scissor or blade, and the anvil head placed into the proximal bowel.
The anvil is xed with a purse string. To maintain pneumoperitoneum, we prefer to
use the Alexis® laparoscopic system with Kii Fios First Entry wound protectors with
a cap (Applied Medical, Rancho Santa Margarita, CA, USA) or simply by using a
Penrose drain around the trocars and wound protector. The anastomosis is achieved
with a circular stapler, introduced through the rectum.
Alternatively, side-to-side isoperistaltic intracorporeal anastomosis can be created by anastomosing the small enterotomies on the proximal and distal portions of
the colon. The lumen of the anastomosis is formed using one or two rings of the
blue-loaded robotic stapler. Enterotomy defects can be closed using barbed sutures
[7]. For intracorporeal anastomosis with a circular stapler, the anvil can be passed
intra-abdominally through the Pfannenstiel incision wound protector. Approximately
2cm proximal to the proximal transection point, a small pinpoint colotomy is performed at the anvil post-exit point. After introducing and positioning the anvil, the
distal colotomy is closed using running barbed sutures [28]. Some surgeons prefer
those alternative techniques. However, we don’t believe these approaches provide
additional benets on minimizing extraction site incision size or recovery benets.
Once the anastomosis completed and hemostasis conrmed especially at the vascular pedicle sites, ports are then removed under direct vision (Video 27.2).
Although the long-term oncological advantages of robotic surgery for rectal and
colon cancers have not been conclusively demonstrated, notable short-term benets
are associated with robotic surgery. Alharthi etal. found that robotic left hemicolectomy is associated with a shorter length of hospital stay and higher total hospital
costs than laparoscopic left hemicolectomy while maintaining comparable postoperative complication rates [29]. Additionally, Bastawrous etal. reported a lower rate
of conversion to open surgery in robotic left hemicolectomy than in laparoscopic
left hemicolectomy [30]. Studies addressing benign lesions, such as diverticula,
have also suggested the feasibility of robotic left hemicolectomy for both simple
and complicated diverticular diseases of the sigmoid colon [31]. The robotic system
has demonstrated effective performance in mobilizing the colonic splenic exure
[32]. Furthermore, increasing evidence supports the safety and effectiveness of
robotic intracorporeal anastomosis in left-sided colon resection. This technique has